Accident Plan

Citi Benefits Handbook

Accident Plan

The Accident Plan complements your medical coverage by providing a cash benefit if you or your covered family members suffer an accidental injury that is covered under the plan. The cash benefit helps pay for out-of-pocket expenses, such as home health care, rehabilitation and medical plan copays. The Accident Plan provides the following.

What's Covered


	Covered	Benefit
Initial care	Ambulance
	Ground ambulance	$300
	Air ambulance	$1,500
	Maximum ground and air ambulance trips combined per accident	1
	Initial treatment
	Emergency room/Hospital	$200
	Physician's office/Urgent care facility	$200
	Walk-in clinic/Telemedicine	$50
	Maximum visits per accident, combined for all places of service	1
	Maximum visits per plan year, combined for all places of service	3
	X-ray	$150
	Lab	$75
	Medical imaging	$250
Follow-up care	Accident follow-up
	Emergency room/Hospital	$100
	Physician's office/Urgent care facility	$100
	Walk-in clinic/Telemedicine	$50
	Maximum visits per accident, combined for all places of service	6
	Maximum visits per plan year, combined for all places of service	No maximum
	Appliances
	Major: Back brace, body jacket, knee scooter, wheelchair, motorized scooter or wheelchair	$200
	Minor: Brace, cane, crutches, walker, walking boot, other medical devices to aid in your physical movement	$200
	Chiropractic treatment and alternative therapy	$50
	Chiropractic treatment and alternative therapy maximum visits per accident	10
	Chiropractic treatment and alternative therapy maximum visits per plan year	30
	Pain management (epidural anesthesia)	$50
	Prescription drugs	$10
	Therapy services – speech, occupational, physical therapy or cognitive rehabilitation	$75
	Therapy services – speech, occupational, physical therapy or cognitive rehabilitation maximum visits per accident	10
	Prosthetic device/Artificial limb
	One limb	$750
	Multiple limbs	$1,500
	Maximum benefit per accident	1
	Repair and replace	25%
	Maximum benefit per plan year	1
Hospital care	Hospital stay (initial day)
	Non-ICU admission	$2,000
	ICU admission	$4,000
	Hospital stay (daily)¹
	Non-ICU	$200
	ICU	$400
	Step down intensive care	$400
	Maximum days per accident (combined for all stays due to the same accident)	365
	Rehabilitation unit stay	$200
	Rehabilitation unit stay maximum days per accident	30
	Observation unit	$100
Surgical care	Blood/Plasma/Platelets	$400
	Eye injury: Surgical repair	$300
	Eye injury: Removal of foreign object	$100
	Surgery (without repair): Arthroscopic or exploratory	$350
	Surgery (with repair)
	Cranial, open abdominal or thoracic	$1,500
	Hernia	$250
	Ruptured disc	$750
	Tendon/Ligament/Rotator cuff single repair	$750
	Tendon/Ligament/Rotator cuff multiple repairs	$1,500
	Torn knee cartilage	$750
	Non-specified inpatient	$750
	Non-specified outpatient	$750
	Maximum benefits per accident, combined for all surgery (without repair) and surgery (with repair)	2
Transportation and lodging assistance	Lodging per day for up to 30 days	$300
	Maximum days per accident	30
	Transportation	$500
Fractures and dislocations	Dislocations (closed reduction)²
	Hip	$4,500
	Knee	$3,000
	Ankle bone or bones of the foot (other than toes)	$1,800
	Collarbone (sternoclavicular)	$2,250
	Lower jaw	$1,350
	Shoulder (glenohumeral)	$2,250
	Elbow	$900
	Wrist	$1,125
	Bones or bones of the hand (other than fingers)	$1,650
	Collarbone (acromioclavicular and separation)	$2,250
	Rib	$300
	One toe or one finger	$375
	Partial dislocation	25%
	Maximum dislocations per accident	3
	Fractures (closed reduction)²
	Skull (except bones of the face or nose), depressed	$6,000
	Skull (except bones of the face or nose), non- depressed	$3,000
	Hip, thigh (femur)	$6,000
	Vertebrae, body of (excluding vertebral processes)	$5,400
	Pelvis (including ilium, ischium, pubis, acetabulum except coccyx)	$4,800
	Leg (tibia and/or fibula malleolus)	$3,750
	Bones of the face or nose (except mandible or maxilla)	$1,800
	Upper jaw, maxilla (except alveolar process)	$2,100
	Upper arm between elbow and shoulder (humerus)	$2,100
	Lower jaw, mandible (except alveolar process)	$2,400
	Collarbone (clavicle, sternum)	$2,400
	Shoulder blade (scapula)	$2,400
	Vertebral process	$1,500
	Forearm (radius and/or ulna)	$3,000
	Kneecap (patella)	$3,000
	Hand/Foot (except fingers or toes)	$3,000
	Ankle/Wrist	$3,000
	Rib	$525
	Coccyx	$525
	Finger, toe	$525
	Chip fracture	25%
	Maximum fractures per accident	3
Paralysis	Home and vehicle alteration	$2,000
	Complete, total and permanent loss
	Quadriplegia	$20,000
	Trilegia	$15,000
	Paraplegia	$10,000
	Hemiplegia	$10,000
	Diplegia	$10,000
	Monoplegia	$5,000
Other accidental injuries	Brain injury
	Concussion/Mild traumatic brain injury	$500
	Moderate/Severe traumatic brain injury	$1,000
	Burn
	Second degree burn, greater than 5% of total body surface	$1,500
	Third degree burn, less than 5% of total body surface	$1,500
	Third degree burn, 5-10% of total body surface	$6,000
	Third degree burn, greater than 10% of total body surface	$25,000
	Burnt skin graft	50% of burn benefit
	Coma
	Coma (non-induced)	$20,000
	PVS	$20,000
	Coma (induced)	$500
	Maximum days per incident	10
	Dental
	Extractions	$75
	Crown	$225
	Laceration
	Without stitches	$25
	With stitches, less than 7.5 centimeters	$100
	With stitches, 7.6 to 20.0 centimeters	$300
	With stitches, greater than 20.0 centimeters	$600
	Other
	Posttraumatic stress disorder (PTSD)	$500
	Maximum PTSD benefit per lifetime	1
	Service dog	$2,500
	Maximum service dogs per lifetime	1

¹ All daily benefits for hospital stays begin on day one.

² Open reduction pays two times the closed reduction benefit.

Additional Benefits

The following additional benefit apply:

Waiver of Premium: If you miss 30 continuous days of work as a result of an accidental injury, your Accident Insurance coverage premium will be waived beginning on the first pay period that occurs after the 30th day of your absence, through the next six months of coverage. You must remain employed to qualify for a waiver of premium. This waiver of premium benefit does not apply to your covered dependents.

Organized Sports Benefit: If you sustain an accidental injury while playing as a registered member of an organized sports activity, your benefit will be increased by 25%. Benefits for burns, burn skin graft and service dog are not included in the organized sports benefit.

Exclusions and Limitations

Benefits for covered accidental injuries will be paid upon a diagnosis that satisfies the requirements of the policy and when all other policy requirements are met. Accident Plan benefits are not payable for any care, service or supply for an accidental injury related to:

Certain competitive or recreational activities, including but not limited to: ballooning, bungee jumping, parachuting, and skydiving;

Any semi-professional or professional competitive athletic contest, including officiating or coaching, for which you receive payment;

Act of war or rioting;

Operating, learning to operate or serving as a pilot or crew member of any aircraft, whether motorized or not;

Assault, felony, illegal occupation, or other criminal act;

Bacterial infections that are not caused by a cut or wound from an accidental injury;

Care provided by immediate family members or any household member;

Elective or cosmetic surgery;

Nutritional supplements;

Suicide or attempt at suicide, intentionally self-inflicted injury, or any attempt at self-inflicted injury, or any form of intentional asphyxiation, except when resulting from a diagnosed disorder;

Violating any cellular device use laws of the state in which the accident occurred, while operating a motor vehicle; or

Accidental injury sustained while intoxicated or under the influence of any drug intoxicant, including those prescribed by a physician that are misused.

Benefits will not be paid for a service or supply rendered or received that are not specifically covered or not related to an accidental injury.

Any service, stay or visit must be on or after the effective date of coverage, while coverage is in force and take place in the United States or its territories.